The distally based posterior tibial adipofascial flap is a useful option for distal leg and ankle coverage. Traditionally, its dimension is constrained by a length-to-width ratio of 2:1. We have increased this ratio to 4:1 by including the great saphenous vein and saphenous nerve with the flap. These structures with their venoneural network, and their connections with posterior tibial artery perforators, form the vascular axis of the flap. In our series of 21 flaps, 70% (n = 15) had ratios of 3:1 or higher. In remaining 30% (n = 6), the ratio was 2:1, as the defects were more proximal. Complications include one complete flap loss due to compression from tunneling and one superficial tip necrosis. Postoperatively, we performed wet-to-wet dressings, phlebotomy, and delayed skin grafting to optimize flap survival. Of 21 flaps, 20 were healthy after an average follow-up of 24 months.

Radial or ulnar oblique amputations treated by nailbed levelling and local digital flap reconstruction can result in significantly shortened fingertip, narrowed pulp and nail shape distortion. A VY type flap containing bone, sterile matrix, and skin was conceptualised to restore nail and pulp contour for coronal oblique amputations. Technical details and a clinical case are discussed.

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Introduction: The surgeon uses different methods of surgical hand antisepsis with the aim of reducing surgical site infections. To date, there are no local studies comparing the efficacy of iodine hand scrub against newer alcohol-based hand rubs with active ingredients. Our pilot study compares a traditional aqueous hand scrub using 7.5% Povidone iodine (PVP-I) against a hand rub using Avagard: 61% ethyl alcohol, 1% chlorhexidine gluconate. The outcome measure is the number of Colony Forming Units (CFU) cultured from 10-digit fingertip imprints on agar plates. Materials and Methods: Ten volunteers underwent 2 hand preparation protocols, with a 30-minute interval in between–Protocol A (3-minute of aqueous scrub using PVP-I) and Protocol B (3-minute of hand rub, until dry, using Avagard). In each protocol, fingertip imprints were obtained immediately after hand preparation (t0). The volunteers proceeded to don sterile gloves and performed specific tasks (suturing). At one hour, the gloves were removed and a second set of imprints was obtained (t1). Results: Four sets of fingertip imprints were obtained. All 10 participants complied with the supervised hand preparation procedures for each protocol. CFUs of initial fingertip imprints (t0): The median CFU counts for initial imprint was significantly higher in the PVP-I treatment (median = 6, Inter Quartile Range (IQR) = 33) compared to the Avagard treatment (median = 0, IQR = 0, P <0.001). CFUs of fingertip imprint at 1 hour (t1): The median CFU counts for second imprint (t1) was significantly higher in the PVP-I treatment (median = 0.5, IQR = 11) compared to the Avagard treatment (median = 0, IQR = 0, P = 0.009). Our results suggest that the Avagard was more efficacious than aqueous PVP-I scrub at reducing baseline colony counts and sustaining this antisepsis effect. Conclusion: Alcohol hand rub with an active compound, demonstrated superior efficacy in CFU reduction. Based on our results, and those pooled from other authors, we suggest that alcohol-based hand rubs could be included in the operating theatre as an alternative to traditional surgical scrub for surgical hand antisepsis. Key words: Alcohol-based, Hand rub, Hand scrub, Surgical hand antisepsis, Surgical site infection